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Monthly Archives: April 2007

Just got back from my 6, er, 9.5 hour EMS (emergency medical service) shift (my medical school has a unique program that sends first year medical students to ride with paramedics to pick up emergency calls). I’m not going to go into much detail tonight (because my shift started at 6pm, and now it’s 4 AM), but I just wanted to mention: I have lots of respect and love for EMTs and parademics now. Briefly, some lessons I’ve learned tonight:

1. When there’s an ambulance truck behind you, GET OUT OF THE WAY! Even if they don’t have their siren on, the truck may be transporting a patient; they might just be taking it slow(er) so as not to cause too much pain to the patient. Nonetheless, that person needs to get to the hospital ASAP. One patient tonight had an post-surgery infection, and boy, did we get an earful each time the truck went over a bump.

2. Don’t be the boy that cried 9-1-1. Twice tonight we received false calls: one from a caller who then disconnected his/her phone line (i.e. prank call, but may have been associated with a mental illness), and another from someone pressing the wrong button on the house alarm. Sometimes there’s not a lot going on, but sometimes there is: EMS is a limited resource, and it’s not cool to waste it. Then again, if you’re sick or in serious pain, use it (because it’s better to be safe than sorry).

3. One thing that never really seemed concrete to me before tonight was the notion that EMS really prepares patients for hospital care. Although doctors and nurses have a much more complicated job regarding diagnosis and treatment, EMS does the initial stabilization of the patient’s condition during the first crucial hour of an acute crisis. Furthermore, while doctors and nurses might subconsciously expect patients to be served up on a silver platter (i.e. presented in a particular, uniform fashion), EMS deals with a very wide variety of situations. What I saw tonight was pretty mild: light blood, projectile vomit (i.e. fountain), diarrhea, nudity, stab wound.

4. With only a few exceptions, I think that paramedics and EMTs are the health care providers that bear witness to the most pain. They’re the first to see trauma, and they’re also the ones who see people in pain before they are sedated or calmed down within the hospital environment. Of the several calls we received, three of the four in which we brought patients back to the hospital were patients in excruciating pain. They weren’t just screaming for attention: you could tell that they were in really, really bad pain. By contrast, and I could be wrong, but I’m under the impression that most doctors and nurses don’t have to deal with as much pain because the patients they see have already been administered analgesics (pain killers), will rapidly be administered pain killers, or they only see individual patients for a few minutes at a time. Some might work with patients in a lot of pain all the time. But they have the ability to leave the room. However, for me and the two paramedics, we had to work with the screaming, pained patients for half an hour or more at a time (moving the patients from their houses to the ambulance truck, riding to the hospital, and then escorting them from the truck through the check-in process and eventually to a hospital bed).

5. People need health insurance. Otherwise, a lot of hospital Emergency Departments simply won’t take the patient seriously. The paramedics and I waited one hour and forty-five minutes with one uninsured patient on the stretcher, just inside the entrance of the ED, while the staff was “trying to find a bed.” This also meant that my team and I missed all of the trauma calls during our shift because of having to wait at this ED next to the stretcher. Another patient came in with another EMS crew half an hour after we arrived, and they immediately received a bed. Our guy was in serious pain, but he was a trooper and tried his best not to cry out. He eventually got a bed, but to me, it seemed clear that the nurses and the doctors weren’t going to go out of their way to take care of this particular patient. Of course, it was late at night, and they were probably all tired. But they definitely shuffled a lot faster for the other incoming patients. It doesn’t surprise me, especially since there is so much more incentive for taking care of paying patients.

6. Like many aspects of this early stage in my medical training, this was a very humbling experience. Even though I’m very happy and confident because of my good bedside manner, decent history-taking, growing ability to do a (decent) Tier One physical exam, and my early proficiency with IV cannuli and laryngoscopes, there are vast realms of medicine in which I have little knowledge or experience. One of these is Emergency Medicine: one Fast Track shift and one long EMS shift later, I still don’t quite get it. By that, I mean I don’t think my personality and approach fit it well. Maybe I just need more experience in this field to get my finger on the pulse, but I think I probably work better with the unknown in a more stable setting (outpatient?) or with more extensive background information and greater complexity in the challenge at hand (intensive care?). It gives me more respect for ED docs like shadowfax and Panda Bear who probably do enjoy the fresh unknown of incoming emergent patients. Either way, as I was standing there next to the patient my team brought into the ED for more than an hour, I really wished that I had enough expertise and knowledge to help him right then and there (since no one else was bothering to).

“… had I known how to save a life.”

While I personally believe that the federal government needs to play an important role in the promotion and establishment of universal health care (that is, facilitating and making sure that everyone has health care coverage, but not necessarily paying for everyone as a single payer), I am amazed by the many instances in which government officials have severely damaged the practice of medicine in the U.S during the Bush Administration. I will mention just a handful that particularly bother me at this time due to their blatant impositions of government authority in medical decisions.

The Current Issue: Partial-Birth Abortion

On April 18, 2007, the Supreme Court upheld the 2003 Partial-Birth Abortion Act in the court case Gonzales vs. Carhart that bans D&X, the safest procedure used in second-trimester abortions. Previously, the 8th Circuit Court of Appeals ruled in favor of partial-birth abortion, until Attorney General Alberto Gonzales appealed the decision and brought it in front of the Supreme Court. The 2003 act was pushed through Congress through the leadership of Senator Bill Frist.

The ruling by the Supreme Court “allows” D&X to be used in cases where the mother’s life is “in imminent danger,” but for no other reason, including in cases where the pregnancy is just “threatening her health.” A series of editorials in this week’s New England Journal of Medicine strongly question this decision, particularly since there is no specification of what degree of mortal risk permits the procedure. The Supreme Court ruling endangers physicians who are involved in reproductive health by further exposing them to prosecution based on an act with vague definitions of what is permissible, what isn’t permissible, and when and where the act applies. Editor-in-Chief Jeffrey Drazen, M.D., asserts that the Judicial branch has joined the Legislative Branch in trying to “practice medicine without a license,” owing to the interference in medical decisions by both branches of government at the expense of the health of patients.

The act states:

(1) A moral, medical, and ethical consensus exists that the practice of performing a partial-birth abortion — an abortion in which a physician delivers an unborn child’s body until only the head remains inside the womb, punctures the back of the child’s skull with a sharp instrument, and sucks the child’s brains out before completing delivery of the dead infant — is a gruesome and inhumane procedure that is never medically necessary and should be prohibited.

(2) Rather than being an abortion procedure that is embraced by the medical community, particularly among physicians who routinely perform other abortion procedures, partial-birth abortion remains a disfavored procedure that is not only unnecessary to preserve the health of the mother, but in fact poses serious risks to the long-term health of women and in some circumstances, their lives. As a result, at least 27 States banned the procedure as did the United States Congress which voted to ban the procedure during the 104th, 105th, and 106th Congresses.

and furthermore:

An abortion in which the person performing the abortion, deliberately and intentionally vaginally delivers a living fetus until, in the case of a head-first presentation, the entire fetal head is outside the body of the mother, or, in the case of breech presentation, any part of the fetal trunk past the navel is outside the body of the mother, for the purpose of performing an overt act that the person knows will kill the partially delivered living fetus; and performs the overt act, other than completion of delivery, that kills the partially delivered living fetus.

The Key Players:

Shameful and Knowing It

1. U.S. Attorney General Alberto Gonzales

That Gonzales has taken on the cause of fighting abortion rights signifies his departure from his prior personal convictions in order to serve as one of President Bush’s many yes-men. He, in fact, was perceived as being in favor of abortion rights, a notion that drew opposition from Republicans prior to his appointment. His term as Attorney General, however, has thus far been marked by conduct consistent with the often inconsistent, incompetent and undeniably frustrating manner exhibited by many Bush appointees. For example, during his testimony in front of Congress on April 19 about the questionable dismissal of eight U.S. attorneys, he stated 71 times in response to questions that he had no memory regarding events surrounding the dismissals. On another occasion, he stated in front of the Senate Judiciary Committee that the U.S Constitution does not guarantee habeas corpus, a statement that was immediately questioned by Senator Arlen Specter.

2. Senator Bill Frist, M.D.

More disturbing on this topic is the conduct of Senator Frist, not only in pushing forth the Partial-Birth Abortion Act of 2003 (as representing the “consensus” of moral, medical, and ethical opinion) but also in his conduct as a representative of the medical communty with Congress. As a physician and the Senate Majority Leader, Senator Frist played a very influential and controversial role as the voice of the American medical community within the Legislative branch of the federal government. However, on numerous occasions, he misled Congress. The most public and obvious of these was in the case of Terri Shiavo, a woman who was in a persistent vegetative state. Dr. Frist, after viewing a home video from Shiavo’s parents (who wanted to keep her on life support indefinitely, unlike her husband, who petitioned to a Florida court to determine whether or not she would have wanted to have life support removed) stated in a speech to Congress that he did not think she was in a persistent vegetative state (a state, unlike coma, from which there is virtually no possibility of recovering consciousness). Although the Florida 6th Circuit court determined that there was convincing evidence from numerous statements and accounts from people close to Shiavo that she would want to have life support removed, Governor Jeb Bush and Congress swooped in to stop the removal of life support. The Republican-led Congress went so far as to subpoena Terri Shiavo and her husband to testify in front of Congress, noting that her inability to do anything would mean that she would be held in contempt of Congress and this would effectively block any attempts to remove her feeding tube.

shiavo.jpeg

This is a CT Scan, the left showing a normal 25-year-old’s brain and the right showing Shiavo’s brain in 2002, three years before she was allowed to die. Now, a neurologist, or even a first year medical student, could tell that someone cannot recover consciousness with that extent of damage to the cerebral cortex. There simply aren’t enough neurons there. Despite this, Dr. Frist compromised his integrity as a physician by disputing the assessment of the Shiavo’s neurologists and effectively asserting to Congress that Shiavo had a chance of regaining consciousness and should not be taken off life support. Not to mention that Dr. Frist is a cardiothoracic surgeon. Now, specialist physicians do have knowledge outside their own specialties, but typically, it’s worth deferring to the opinion of a specialist in the field in question (i.e. the neurologist for neurological issues).

Dr. Frist doesn’t represent the medical community, and if anything, seems to have done a disservice to medicine and patients. While he may have been an excellent physician prior to his political career, it seems that he has taken considerable measures toward rejecting the professional integrity with which physicians are supposed to conduct themselves in order to further his political career. This is quite unfortunate, because his example will undoubtedly discourage other more credible physicians from pursuing political careers with ideal aims.

Strong Enough to Brave the Fire

Dr. LeRoy Carhart – I know nothing about this man, except that he is a practicing physician who has taken a stand on a highly-charged, political issue with profound impact on his practice of medicine. Dr. Carhart is one of three abortion providers in the state of Nebraska, and he challenged the 2003 Partial-Birth Abortion ban in the U.S. 8th Circuit Court of Appeals. Like many abortion providers, he has been the target of violence: at least on one occasion, arsonists (presumably anti-abortion activists) set fire to his house and farm, killing pets and livestock and destroying much property.

Nonetheless, he is still pursuing this cause: not out of financial profit or because he hates babies, but probably because he believes that there are real-life situations where mothers must choose abortion in order to avoid serious risks to their health (not just lethal risks). After all, how can one expect a mother to be able to take care of her child if she is severely debilitated by the pregnancy? Would the child, looking back at the situation after birth, even have wanted to be born under those conditions? These risks to health may not be apparent until the second trimester, and the risk to life may not fully develop until after the second trimester. What then? The Supreme Court and Congress have just given this woman a death sentence – or the physician a prison term for trying to save her life.

I have profound respect for abortion providers. No doctor delights in killing. But good doctors do uphold the wishes of their patients that correspond with improvements in happiness and health, even if it means ending life. One major change in the provision of end-of-life care is the emphasis on patient autonomy: if a patient would die without life support and expresses that desire (himself/herself, through a power of attorney or living will, or if sufficient evidence is demonstrated of that desire), then physicians must allow the patient to die rather than needlessly take heroic measures to keep him/her alive. In a way, this is exactly what Congress and the Supreme Court have done during the Bush administration: take heroic measures to preserve life, at the expense of the wishes of the patients.

Concluding Thoughts

My political views tend toward the liberal, but my approach tends to be more moderate. I listen to both conservative and liberal views, as there is wisdom to gain from all sides and progress to be made in the space between. However, several changes to medical practice enforced by Bush administration-led entities have constituted serious breaches into the doctor-patient relationship and the ability of doctors to provide services to patients. Unless the medical community and its allies inside and outside government take a stand, this trend may just get worse. My hope is that future presidential administrations have more foresight and respect for patients, particularly women. This administration has, through its appointments in the Supreme Court and the FDA and through Congress, shown contempt for both women and the autonomy and authority of physicians in medical decision-making. If we know any better, we won’t let this happen again.

Lately, I’ve been reading more and more medical blogs, and it has been interesting reading that of an Emergency Medicine resident who comments at length about health care coverage. While I sometimes find his writing to be dramaticized and overly cathartic (as amusingly demonstrated by both his comment thread fans and his passionate critics), he tends toward intelligent commentary and analysis of the push for universal health care. Furthermore, his stance is decidedly conservative, and I would likely find my future pursuits to only appeal to half of this country if I didn’t at least occasionally listen to perspectives such as his.

I’m still trying to figure out my own perspectives on what universal health care would ultimately mean for the U.S., and how it would best be implemented. While I don’t necessarily believe in single-payer systems, I do think that charity-based “safety net” health care should eventually be phased out (albeit at different rates for each region): New Orleans is the perfect example of a city that currently needs a safety net, but can benefit from setting a timeline toward mandate-based policies requiring and facilitating health insurance ownership/coverage for all citizens (as currently in the process of being implemented in Massachusetts, which is the plan Secretary Leavitt is trying to force on Louisiana at a time when it might not be feasible – the verdict is still out).

On the one hand, there is the notion that we need to reduce health care costs. This is reasonable, but it is based on faulty interpretations. It is commonly cited that the U.S. spends more than any other country on health care, but it doesn’t have the best outcomes or population statistics (life expectancy, infant mortality, etc.). This is partly due to health care inequalities (the life expectancy for one community of East Asian women in New Jersey is 80+, while the life expectancy of Native American men in another community in North Dakota is around 55). This is also due to the large investments that the U.S. places on discovery: research and development of new treatments and medical technology (of which the U.S. produces more than any other country). Furthermore, Americans (who do pay for health care) pay for convenience and excellence: we pay for shorter waiting times (minutes or hours for tests, imaging studies, and procedures instead of days or months), and we also pay for the most highly trained physicians (high profiles figures in other countries are often sent to the U.S. for acute medical conditions). Lastly, the U.S. is a big, heterogenous country: in some ways, it’s like 50 smaller countries. Health care, depending on your measurement and subjective perspective, can vary considerably from state to state.

On the other hand, there is some compulsion toward “providing” health care for all American citizens. Some say it’s a right and criticize our willingness to propagate health care disparities that uphold socioeconomic disparities. Others point to the swelling of Emergency Departments with uninsured patients and the notion that these patients drive up costs for everyone else. Others argue that a penny in prevention saves a hundred dollars in later acute care. Others (me) suggest that people aren’t nearly as productive toward society when they’re sick and disabled as they could be when they’re more healthy. These are just a few reasons – there are probably more I’m forgetting to mention.

It seems that things aren’t going to get any better if we do nothing. However, if we push for some rendition of universal health care, we have to do it in a way that actually solves problems. Panda Bear points out in his comment thread that improving access doesn’t necessarily result in better health, especially since improved access doesn’t equate with improved usage of health care resources. I completely agree. However, this information is weak support (at best) for the argument that primary care for the poor and uninsured is a lost cause.

Where I disagree is in the assumption that people cannot make the right decision (because they currently aren’t making the decisions to improve their own health statuses). My thoughts on this issue coalesced (in my post-exam, semi-cogent state) when I read shadowfax’s criticism of Panda Bear’s reference to poor people as “people who don’t think and plan ahead.” It is often stated (usually by conservatives) that people make bad choices, and accordingly, we shouldn’t go out of our way to help them. Instead, it is argued that we should only help those who help themselves (assuming that we, the doctors, are in the right position to judge this). What sense does it make to applaud people who can afford health care when they choose to seek health care and criticize people who can’t afford it when they choose not to seek care? That is the current state of affairs. Now, if everyone were hypothetically covered by health insurance, would it make any more sense to criticize those people who still aren’t seeking primary health care?

My argument: no, that does not make sense. Why? People make decisions based on varying degrees of acquired information, and information disparities are considerable. One example is with smoking. Everyone knows that smoking is bad for you, but they don’t know why. Most people think that smoking leads to lung cancer, but this is only one effect: tobacco use also dramatically increases the risk of heart attacks and strokes. Furthermore, people say, “I’m going to die of something anyways.” What they don’t realize is how much pain and suffering they might have before they die, or how prematurely they may die. Pain and suffering from: not being able to breathe, gangrene, blindness, pain and lack of physical mobility due to heart failure, not being able to sleep well because of fluid in your lungs, losing mental and motor faculties because of a stroke, etc. Sure, everyone dies: but who dies in their forties and fifties these days? Who wants to spend the last decades of their life trying to sleep with three pillows tucked behind their backs because they feeling like they’re drowning when they lie down?

The CDC/U.S. Department of Health and Human Service’s “Chartbook on Trends in the Health of Americans” shows extensive data indicating that increased years of education correlate with reduced prevalance of smoking. In 2004, 29.1% of people who didn’t graduate from high school or get a GED smoked, 25.8% of those who did graduate, 21.4% with some college education, and only 10% of those who graduated from college smoked. While this correlation isn’t a proof of causation, it does suggest that people with access to more knowledge may have more accurate health knowledge on which to base their decisions. It’s a problem of value: some people don’t know the true value of health care they receive or preventive measures they might take. If they did, they might make the right choices (or try harder to, despite other obstacles such as financial costs, difficulty in finding resources, etc.).

I’d like to recall my story some months back about the young mother with her little girl that had a high fever and a bad cough. When I first saw her, the first thought on my mind was that she could be a typical, angry, impudent, noncompliant, charity patient with a tendency toward making bad decisions. However, that interpretation didn’t stick: it was completely wrong. The young mother had been waiting in the ER for almost eight hours; there were other places she needed to be. However, because she was worried about her girl, she came into the ER, foregoing a day’s worth of pay. However, as she waited for the chest x-ray, her doubts grew as to whether or not her daughter was really that sick. After all, it probably was just a bad cold, right? When the attending physician came to berate her for considering leaving AMA (Against Medical Advice), she obviously wasn’t happy. This physician was essentially accusing her of child abuse and putting her little girl in mortal danger. When the attending physician went away, she turned to me and showered me with questions. What is this medication for? What was the chest x-ray for? Why? She had no idea that pneumonia could be lethal: that up to 20% of untreated cases of pneumonia result in death. The doctors needed to determine whether her girl had pneumonia or acute bronchitis, but she had no idea why she was waiting for so long: if anyone had explained it to her, the message didn’t get across until she asked me. Was this privileged or complicated knowledge that I was passing along? No. But without it, she or someone else in a similar situation could have made a very bad decision. What if she didn’t even come in the next time? We might have a little girl with a fractured foot who might limp for the rest of her life. Or perhaps something worse. Either way, we might take the overly simplistic action of blaming the mother for making bad decisions. But we would be wrong.

Later this week, I’m going to be riding a six-hour shift in an ambulance truck with paramedics. This ambulance ride program is required for all first year medical students at my school. Though there is relatively little diagnostic expertise I can offer (at the most, I can do a Tier One physical examination and perform CPR), I plan to arm myself with what knowledge I do have available to me at this stage in my training that I might be able to pass on to others. The program director left us with the words you so often hear from the mouths of patients, parents, and family members in so many Emergency Rooms: “If only I had known.”

A skeptic might suggest that this is just an excuse; that people do know. However, this is the view of someone who blindly doesn’t understand why people don’t have the information they need. I have always been interested and acutely aware of deficits in knowledge, their effects on how much people can achieve, and what measures may be taken to amend this shortage of knowledge. Perhaps it may be worth it for me to make it a goal to make sure that “If only I had known” is a phrase that is never used again in the context of health care. At least, as it is used now.

Medicine, at its core, is a profession of storytelling: receiving, retelling, and acting. In light of suffering and disease, there is a powerful impulse toward telling others of our plight. As physicians, an important aspect of our role is to receive these stories: this early step in healing not only informs our later interventions, but it also serves as a method of healing itself. Though we seek to provide our patients with as much autonomy as they need and desire, there is considerable relief provided when you know that you won’t have to endure this suffering and fight this disease alone – there is an angel by your side. Physicians don’t act in isolation: we retell the stories of our patients, whether as medical students and residents reporting to attending physicians, practicing physicians consulting our colleagues, or even as writers of case reports in medical journals or presenters in M&M (Morbidity and Mortality) sessions. This is all part of the process of delivering medical care, evaluating mistakes or unforeseen outcomes, and improving the practice of medicine. Storytelling, furthermore, is the platform on which we build our humanity and our connections to others. Lastly, with the stories of our patients in our minds, we must decide how to act.

There is powerful symbolism in the one instrument that all physicians carry with them: the stethoscope. It emphasizes that in order to heal, we must listen: to the stories of our patients, from their minds and from their bodies.

Madonna

Like many, she was born to a family that had lost everything in the second World War. As if poverty in a land with little social welfare wasn’t a hard enough challenge to live with, she had an even more difficult obstacle in front of her: she was a girl. Once her brother was born a year later, any dreams and aspirations she may someday develop were dead on arrival. Despite the scarcity of food, her brother was fed well enough; she was left with scraps and bones. Once as a small child, she broke her arm while walking home from school; her mother didn’t noticed until the next day. She did grow up and made it through high school, where she found her religious faith and secretly harbored hopes of becoming a nun. However, the nuns who taught her, recognizing her intelligence, her creativity, and her quality as a great listener, as well as her compassion, encouraged her to try to go to college and pursue an interest that would fully express all of her qualities. Despite the odds, she made it to college and met the man she would someday marry. They fell in love, and as they were looking toward the future, she decided to pursue a dream that had been developing for some time: she decided that she wanted to become a doctor. She had the heart, the mind, and the soul for this pursuit, and it seemed to be a natural fit.

However, her mother forbade it: how could she be so selfish, putting her own interests and dreams before the welfare of her family, especially when her brother could pursue the same career and make more money to support all of them? As her boyfriend trained in his own career in the U.S., she boarded a plane to this foreign place, leaving behind the few comforts of her home and her family in order to work in the U.S. and send money home. And that, she did: working in sweatshops, first in San Francisco, and then in New York City, obediently sending home the wages she made. Angered that she was being forced to slave away to fund her brother’s medical education, her boyfriend flew up to New York and married her on the spot, severing ties of dependence from her family.

For many years, they lived together happily, raising two sons. However, she never had the chance or the money to go back to medical school: instead, she did what she could, first working as a nursing assistant in a hospital and then as a tech in her husband’s research lab. If she couldn’t pursue her own dreams directly, perhaps she could still contribute to the welfare of others through teaching. And that, she did: she was sent to train in some of the top research facilities around the country so that she could return and teach researchers, medical students, and fellows.

The pair moved many times, finding better paying jobs and rapidly pulling themselves out of the poverty of their youth. However, she started developing abdominal pains, unexplained and sudden. Having dealt with pain and considerable suffering before, she didn’t think to complain or to see a doctor. Months passed, and the pain kept getting worse, sometimes making her cry out at night. Her husband didn’t know what to do: he was so frightened, and furthermore worried that the neighbors would think that he was abusing her. On the other side of the wall, her children lay awake in their beds, paralyzed and confused. She lost her appetite almost completely, and was only able to eat mint candies. He ceased his usual complaints about her “junk food” eating habits that he attributed to the days before they married. Eventually, they went to see the doctor: she had a rare and lethal form of ovarian cancer (sarcoma). The oncologist recommended surgery, which proceeded without complication. However, she wasn’t expected to live long. Her strength and appetite recovered, however, and her pain subsided. She went back to work, her children continued to grow, and life went on.

Soon, a new milestone in their live together arrived: her eldest son was accepted to an Ivy League college! She was very proud and happy, though this new development proved a challenge as her eldest son found college to be very disheartening and difficult. She and her husband did what they could to support him through the experience, despite her quiet knowledge of her cancer’s return. Surprisingly, during this time, she returned to visit her mother who was lying on her death bed. Her brother, however, now a well-respected doctor, refused to prescribe stronger pain killers for her than what could be found over the counter, further fueling the anger of her husband at the insensitivity of her family. Finally, when the spring semester grades arrived with her elder son excelling in his courses, she breathed a sigh of relief. Two weeks later, she was brought to the hospital, the pain of the cancer having reached a new peak.

She spent two weeks in the hospital with palliative care to minimize the pain. Her two sons and her husband stayed with her each day, talking to her, reading her poems, and trying their best to express everything they wanted to say. At one point, her temperature dropped rapidly, and when no nurses could be found, the three piled clean towels on her until she recovered to her normal body temperature. Excited by any sign of improvement, her youngest son went outside to greet the rounding doctor, wondering out loud when his mother would be able to return home. The doctor stared at him blankly, and saying nothing, went inside to check on her patient. In that moment, her youngest son finally received her pronouncement of death, without a sad smile, a hand on the shoulder, or a word from the physician. Saying their last goodbyes, the two sons were sent home, and her husband remained with her until her heart stopped beating, just shy of midnight before Bastille Day. Perhaps now, she was finally free of the pain and suffering. However, in life, though she couldn’t help but show the pain, she never showed herself to suffer. She was 49 years old.

A friend of mine once described to me her motivation for pursuing a career as a criminal defense lawyer: “These [criminals] are people who are alone at the edge of existence. Imagine how frightening, how cruel it would be to be in their position, hated and abandoned. I want to stand there beside them and help them find some peace, help them find what is best for them.” (This is a poor reproduction of her expression which was much more eloquent.) When she spoke these words to me, I knew exactly what she meant: this was precisely what I hoped to do as a physician. In the midst of their suffering, deterioration and pain, my hope is to reach out to my patients in their darkest hour, show them that they aren’t alone, and help guide them out of the darkness and toward their desired destinations (be it a recovered or adapted life or a death without suffering, emotional or physical). Accordingly, I have some inclination toward the field of critical care (or any field where patients have a substantial risk of death). Having known and seen pain, suffering, and death, I feel somewhat better suited than most physicians-in-training toward confronting death or the risk of death on a daily basis.

However, no matter how much death I might see, I hope that I will never be desensitized to the range of accompanying emotions. The end of life can be both tragic and relieving, depending on the ways in which the dying and the living deal with it. Death may bring an end to years of pain from cancer, perhaps if he is lucky, after the patient has accomplished as much as he believes he can in life (with respect to family, work, and personal goals). However, death can also be seen to truncate a life that might have lasted much longer, a life with much potential for bringing meaning to the lives of others. It is this seemingly meaningless shortening of life that makes us sad, because we wonder, “Why did this happen? What did he ever do to deserve this?”

How can we ever understand premature deaths? How can we ever begin to assign meaning or find peaceful resolution to endings so sudden, whether from senseless killing by a deadly virus or by a spray of bullets? We, as a society, have yet to develop a tolerance, let alone an understanding, for the carrier of the disease. It is bad enough to carry a disease in the body, the contagion of stigmatization and isolation spreading with each hacking cough. It is worse still to carry a disease of the mind, especially when our society is so paralyzed by the fear of losing control, for when you lose control you lose independence. The brain is the control center for the human machine, and there is nothing more alien and threatening than a brain gone awry. It took our society so long to begin to accept the idea of mental illness, and the gap between neurology and psychiatry (and the relatively sluggish drive toward unifying the two scientific fields) is evidence of the unwillingness of our society to acknowledge our deepset fear.

As the popular media, in its own disgustingly self-serving way, continues to dramatically villify and demonize the one man we would all like to hold responsible for this most recent tragedy, the nature and source of the disease suffered by this carrier remains elusive. That may be because we don’t want to see it. We live in a society that fails to both properly mediate the effects of stress and properly address the treatment and management of mental illness such as depression and anxiety disorders. [Current theory suggests that chronic stress leads to elevated levels of cortisol which may cause irreversible toxic damage to the hippocampus and amygdala, affecting the emotional processing functions of the brain and inducing the development of clinical depression.] However much doctors may attempt to treat disease, all efforts may be meaningless in the long term if the progenitor of the disease remains intact. That is, we may be able to treat depression, but the positive effects of these medical efforts may be thwarted by a society that stigmatizies, isolates, and alienates. In some ways, he carried not only the contagion of his own self-made frustration, but also the anger of isolation bestowed upon him by each person who neglected to see beyond their own needs and interests at someone who needed help. The price? Outbreak, and the death of so many people. There is so much regret that can be felt in so many places; what could possibly have been done?

On April 16, a Virginia Tech student murdered 30 people and took his own life. Since January 1, there have been at least 54 victims of murder in the city of New Orleans. To date, the United Nations estimates that 450,000 have died of violence or disease as a result of the genocide in Darfur, Sudan. These are presented in order of the magnitude of popular media coverage and their stimulation of the national consciousness, from most to least. Nonetheless, regardless of the magnitude of the numbers of deaths, all of these are incidences of senseless violence. How do we respond? With apathy, with tears, with anger and bigoted rage? To Monday’s killings, ignorance may make excuses and say, “He was clearly messed up.” To the murders in New Orleans, ignorance may say, “They’re just gang members and drug dealers killing each other.” To the killings in Darfur, ignorance may say, “Where’s that?”

It’s easy to want to forget, to not acknowledge the apparent sadness in light of your own life and your own occupations. However, by cutting off emotion, by ignoring that which begs for your attention and sympathy, you are taking the first step toward letting history, and tragedy, repeat itself. We cannot cure our society of its ills if we fail to acknowledge our own collective failures: they are our own, not those of someone else, because we share in the blame and the responsibility. If not with the downfall of this individual, perhaps with another.

To this effect, I would like to take one small step toward making known the story of one individual and his efforts: the Virginia Tech professor who barred a classroom door to give his students time to escape while he himself was killed. The professor was a Holocaust survivor, and one might wonder with a terrible feeling of sadness and futility, “He survived that in order to die like this?” I think that if this man were to look back on his life, regardless of his other accomplishments in the interim period, he might say in response, “I was saved so that I may save the lives of others.”

Knowing this, knowing that this man gave his life to save others, might you be willing to be overwhelmed with sadness at this moment and resolve to do what you can to make sure that this tragedy never happens again?

I feel privileged to have befriended and learned from a number of amazing physicians, researchers, and teachers over the past several years. I only wish that all young doctors could learn and grow from their interactions with individuals such as these. In order to show my gratitude and also help me chart my own development in a different way (by inspiration and influence), I would like to give my thanks to those who have or had the most greatest influence on me (more or less chronologically). There are many others and there will be many others, but here is a start:

To Dr. Roy S. Weiner of the Tulane Cancer Center, the first physician I ever shadowed, for believing many years ago that someone so young could have reason to be passionate and serious about a career in medicine.

To Dr. Jeffrey M. Drazen of the New England Journal of Medicine, for encouraging me to be strong of mind and decisive, even if that means taking a firm stand on a thin line between two seemingly conflicting sides.

To Dr. Caren G. Solomon of the New England Journal of Medicine, for showing me that it is possible to be a practicing physician, an editor, a medical school and clinical instructor, and an academic leader, all while raising a family – and doing all of them excellently, too.

To Professor Daniel Tschumperlin of the Harvard School of Public Health, for giving me the chance to be an independent thinker while conducting my senior thesis research, and for helping me realize that research can actually be personally rewarding.

To Professor Douglas Melton of the Harvard Stem Cell Institute, for teaching me (through his undergraduate/graduate seminar course “Stem Cells and Cloning”) to analyze the world with the appropriate degree of skepticism and criticism.

To Dr. Christopher Murray of the Harvard School of Public Health and formerly of the World Health Organization, for teaching me (through his undergraduate course “International Public Health”) to take a step back in order to see the bigger picture and the broader implications of health care initiatives and my own efforts.

To Dr. Jeffrey G. Wiese of Tulane University School of Medicine, for teaching me (through his clinical skills training component of the course “Foundations in Medicine”) to abandon, upon entering the doors of medical school, the weak tendency to be judgmental of others, and for teaching me the value of excellence in patient interviewing, physical examination, and quantitative analysis in clinical diagnostics.

To Dr. Sandor Vigh of Tulane University School of Medicine, his Anatomy instructor staff (of accomplished, retired surgeons), and anonymous, the cadaver donor, for teaching me the beauty of the functional human body.

To Dr. Frederick J. Kushner of West Jefferson Hospital, for showing me how to truly gain the trust and respect of one’s patients.

To Miya E. Bernson, a future physician, for reminding me to always view each person I meet, whether for the first time or the last time, as a fellow human being, and for inspiring me to believe in the practice of medicine as being one of the greatest expressions of humanity and commonality.

And to my father, Professor Wai-Choi Leung, for instilling in me, despite all the hardship and setbacks my family has suffered across generations, the unshakeable desire to change the world for good.

It’s important for physicians to have strong convictions to guide their practice of medicine. These convictions, however, should be compatible with the code of ethics of the medical profession and informed by the needs that we subserve: the needs of our patients. Though only a first year medical student, I believe that it’s important for me to have guiding principles, state them openly, and be willing to discuss them (and possibly adjust them) when others wish to challenge or encourage them.

1. Everyone should have health care coverage, and physicians should fight for this.

The issue of universal health care coverage is a very controversial issue, partly because so many people believe that a single solution can solve many of health care’s greatest problems everywhere at the same time. Similarly, some people criticize the idea of universal health care coverage because they know, or at least suspect, that current proposals will inevitably fail where they practice (and that this suggests that these proposals will fail everywhere). This probably is not the case: no single solution will bring an answer to health care problems in every country, state, city, and practice setting – at least, not all at once. Some states, like Massachusetts, may benefit dramatically from mandate-based health care policies requiring that each individual purchase a health care insurance plan (and if they can’t afford it, they will receive assistance from the government in purchasing private plans). Some states, like Louisiana, may not be ready for this sort of plan, and may instead benefit from a slower transition from a charity-based safety net system to a system where everyone has their own plan.

Nonetheless, physicians should believe that every patient should have some degree of health care coverage, regardless of the single payer vs. multiple payer debate. It doesn’t matter whether one believes that health care is or isn’t a right. From a practical standpoint alone, it is much better for hospitals to receive reimbursements for care of otherwise uninsured patients, better for the reduction of health care costs overall to make preventive care and primary care more accessible to otherwise uninsured patients, and better for primary care physicians and family practitioners as there would be greater demand for the type of care they provide.

Physicians don’t necessarily have to agree on which health care policy would be best for everyone. However, it is important that physicians care and try to develop or push for plans that will be best for their practice settings (both for themselves and their patients).

2. The worst of enemies may also be your strongest allies.

Physicians tend to villify the forces in health care that make their lives, and the lives of their patients, very difficult: pharmaceutical and biotechnology companies, health insurance providers, and perhaps worst of all, personal liability (aka malpractice) lawyers. While physicians pride themselves on their collective professionalism and integrity (at a much greater efficiency than most other professional groups), there are countless, high-profile examples of the aforementioned entities blatantly lying to the detriment of patients (i.e. pharmaceutical companies hiding adverse results of drug trials, health insurance providers neglecting to pay for care while waiting for their enrollees to die, and malpractice lawyers bending evidence to convince non-medically competent juries of a doctor’s fault).

However, for physicians, a disturbing fact remains that allows these forces to remain in existence, and do so with insufficient regulation from the government: all of these provide valuable resources to health care (although the value of the current delivery of each is highly tenous). Pharmaceutical and biotech companies, though heavily profit-driven, provide health care with valuable new treatments and technology to improve the practice of medicine to some degree (although at the same time raising health care costs). Health insurance providers provide coverage to buffer patients from the increasingly higher costs of health care treatments and technology that might otherwise bankrupt them (aka “catastrophic” health care costs, albeit many insurance companies are failing, sometimes intentionally, to provide adequate coverage). Personal liability lawyers, so-called “ambulance chasers,” are perhaps the least redeemable of these villains, but at the same time, on principle, they attempt to enforce a degree of accountability for the actions of physicians that are inappropriate (although they currently do an extremely bad job of identifying which physicians are trouble makers). All of these entitries are perceived, by physicians and often the general public, as being primarily interested in their own profit. Nonetheless, in name and principle, they provide valuable services.

Furthermore, there are members of these organizations that are not only redeemable, but they are actively seeking to do good and to improve the images of these entities. In order to truly bring about change, physicians could do so much more if they are able to ally with pharmaceutical and biotech companies that are producing affordable and meaningful new treatments and technology (rather than copycat drugs or technologies that don’t actually improvement treatment or diagnosis in a cost-effective manner), insurance companies that are truly trying to limit health care costs while providing adequate coverage for all of their enrollees (including sick, low-income patients), and lawyers who agree to develop physician-lawyer committees that screen malpractice lawsuits for validity before going to trial. They may be hard to find at this point in time, but we will only be shooting ourselves in the foot if we continue to indiscriminately point fingers, thus making these potential allies even harder to find.

3. The patient’s need is the greatest goal.

This should be obvious, but people argue about what constitutes this “need.” Over the past several years, there has been a much greater emphasis in the medical profession on patient autonomy: that is, physicians need to pay more attention to what patients desire. Previously, the doctor’s prerogative carried greater weight. Nonetheless, there are important limitations to patient autonomy: physicians are not required to provide treatments that patients demand. That is, a PCP doesn’t need to write prescriptions for drugs that a patient demands when she feels that he doesn’t need them, and an ER doctor need not deplete his hospital’s or clinic’s blood supply by continuously giving transfusions to a patient whose bleeding cannot be stopped. There have been a select few individual court cases that contradict these general practices, but the just nature of those decisions are questionable.

However, there are two important situations where I believe that the patient’s desire should override the personal convictions of the physician (or pharmacist): the cessation of life support in end-of-life care, and the provision of the morning-after pill. In the former, although an intensivist may wish to convince the patient or his/her family that a disabled life after intensive care can still be very valuable and enjoyable, it is still the patient’s decision (or the decision of his proxy, aka the person with the power of attorney) whether or not to remain on life support. Similarly, as recently ruled in Washington state, pharmacists should fill prescriptions for the morning-after pill, regardless of their personal and/or religious convictions. In both cases, one cannot practice ethically and morally while enforcing one’s personal and/or religious beliefs on another person.

4. Physicians should not be judgmental.

It is absolutely essential for physicians to be critical and skeptical, of their patients as well as their colleagues. However, judging also carries the weight of blame, and we should not be placing blame on anybody as this impairs our ability to care for others (again, patients and fellow colleagues alike).

5. Physicians can make a big difference, and we have the potential to be great leaders.

I believe that there is no excuse for physicians to neglect problems in health care. In other words, apathy is the greatest sin for a physician. While physicians as a professional group may have a significant degree of homogeneity with respect to integrity and professional behavior as compared to other professional groups, there is great variability in the degree to which physicians engage in health care issues outside their own clinical practices (if they practice clinically at all). Physicians in private practice almost invariably have less “spare time” than physicians in academic hospitals due to the high patient volumes set by their clinic or hospital administrations to generate revenue (or set by themselves). Nonetheless, there are so many ways in which all physicians can participate in larger health care reform efforts, particularly with our individual actions, convictions, our voices. Physicians receive considerable respect for being (on average) the smartest, most refined, most worldly, and most well-meaning members of many communities. This respect, however, should not go to waste: we should use the respect given to us in a meaningful way by vocalizing our thoughts on our society’s current problems and our ideas for improvement.

Similarly, although we as physicians (or in my case and those of my colleagues, future physicians) feel entitled to our esteemed positions by the fact that we have to buy our right to practice medicine (i.e. by placing ourself $250,000+ in debt), we are privileged and blessed in the respect that we have been selected to perform a duty to mankind: to care for our fellow man, and attend to the needs of our society. If we see people in need, we should try to help them to the best of our ability. To do nothing is a breach of ethics. Other forces in health care (that might hinder this goal, such as by providing little reimbursement or by threatening litigation) should help facilitate this goal of giving aid to those who need help: it is this desire to help our sick (whether out of humanity or practicality) that made our ancestors the first humans, and that make us human.

On a practical level, helping the sick (even if they are poor investments, noncompliant, and belligerent), is a great service to society: health care disparities are a major factor contributing to financial and social drains on our society (i.e. charity health care costs, crime, unemployment, welfare, etc.) because people cannot be productive members of society if they are sick. On a humanistic level, we are all human beings, and there is perhaps nothing in life that is good and worthwhile (including medicine) that doesn’t reassert this truth.

A quote recently passed along to me by my girlfriend, another future physician:

“I am only one, but still I am one. I cannot do everything, but still I can do something; and because I cannot do everything I will not refuse to do the something I can do.” – Edward Everett Hale

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